Loading...
HomeMy WebLinkAbout96-06517 \ . . ~ ! II I: I , , , ~ , ct. :J ~ VJ ~ > ~ I I 'I ~ I :J' " ~ V) " 'I - . .. '. :) - t"'-- -... \r) -....) ~ ~ ;! 'I 'j j , I, . . " " I, " I , .1 ! " ~, L'IJ ;III'~; 'f,1 " ')i ,. ',A , ,', ';I ,'Ii I Ii) _c',1 ','(; " ~~ 1,1 I" 'il I " I'i:i I ,I(!lt\ m~ "'l'b ;",'{ ':':i~ ;"~;\~ i;l~ 'q;i,. JJ ;~( :1(1'1 , -1'- )II, ,"./;)' ;CN ;,":'11 "'ji';'i'i 'il':'lit,r :'\:~,)~'~ , '11,,\1) , "'II::fi?, I.., I;:~i?\ I !iK '1'~'/~l '_ ',l!~J, , ,'tli;_) , , i~'~ · . ',; ,I-'i:.il \-'-,,\\; 'b.".' ; it-r'\!,Hf,~ ' " " I, , "J I , .I. I:tc l, , 10 \'\ ,~ '- I .\ Ii " 0' n " I I II ii, ,,) {;\ , , il ;1 ;'1 , ;",i , , ~ " PITITIONIR'S IXHIIIT , ~ CllrlHI'lhlHl'lIal ~, 1I\lllh'"I!h,HI~'Vh'I'I~ " ' , I , . IllIh hhll'I CONVENmNT CARE/EMEI10ENCY IlEOISTRATION '..n"'nllil~1~11~\l"':1Mf'l . ""'io'i^I,I,IVJJi!1JJ Jlrilll''''''I'nff - -, 1'1'''' If>\' I" 1'\l'I'NII"~I'I'''~1V1/T_-- O:t:lll/ill 1I/III/'IIi 1~.lj'l 1:11: " ~O 01 O~ II :l311~1I1/i 1W\\"'i1mnJJJr-' lll~dllh'" '''''jlljjdl''\j 11111 Il'~Jll"1 TItrTTnrW'i ""IFLII" ~II ll/lli/~1i HUHE llllJflll'lllnJln1l1171Jll7ftI>JP'''lIlft. (111) 37~'!Y12' - ]l1,',,' 01''''''""",11, - ---,-,-._,..--.. -... BTIIUFFEM, LIINNIE n. allv F II II rMnHMl.IH 1:1,1I1111HII 1:11 :II .Nllno or 03/:1:1/1111 1,IIMIIIlH IIVIH"l lIIIi-!lO-1Ii9!) lilt 1I','r H till llM II , I'll OlllPPEH0811MII, pn 17:1117 T,IJII'71lVnmr:J1;<lK"r.nJr,.nrn'1,nrni:'-f1111 !Y:t2~tl12"-'-' IllllllrFlM, JFFfFMV L. :II IIMIIIIII Ill' 1\' ;~Jl'J;11 wl f.1 \,..(~ j-;:r n' 11111 PPEHllllllNII , pn II:lnl llJJl? " JUl11fr1:'ni;-llW .1';11 m:-llrl!:"","1'li 1/.-;"_ I (, ~ ,- ~ Ii.. (,!l ~ II I:IINIJIlU IlVH'U: I' U IIUX 1000 I:IlNLJIlLE, ~II 1/013 1It:1/1"--r.llOnn --':!li I'''''' ,-- 1I1l1116~~Ii(in:l!l 31; I nrUUFFEN, JEFfENV L. THfn:\{ I~.'i li;'l ir)"--' ..--.~,---_.._---- ""IELIIIl, UINIIIHIII (117 Hj:I:I"~!I11 III ..-------01------ ,-----. O:l:l~II~OOO 0:1 'J'itJ.T.TiljTi'i1i.\~iri,-.._-,...__._..._-._-~~--t----- IIC NECCIIEI:K II"HnH IlITE N ItIlNI) jl~I)j;N ~jr~!n)J,~f" __'__'___'~__~____~~n.__..'__.___ Illl "--'I~~~I~'~;IHII, IIHTllIIHV ;J HIIH!:, NEFllUElI- -- --+-+-,- ~-_. --. ~ - - -.- - _.__._---,_._~-~--~---- 111111'.1' YHil'f ~0700 ~o 710 CI At)!; I VH;II Cl. ASn II VIGil ~O 720 Cl.Mm11lV161l ~0730 CiMi!\ IY Will ~0740 ctMm Y Will ~0760 CONYENiI'NI CM'F I ~70~0 CONYFNII'N' CM'" II ~10~6 MINOllliLJ1LJIII' EllS 01 EllS O~ EllS 03 EllS 04 EOS 06 MEIlILJM !III' LJIIE MA.IOllliIlJllllE INJlJI1AlION IV G(:T UP CM11JIM: MONIIOIl EOS 11 EOS 14 PELYIC EXAM NIIlIO liEl,l!P EOS 16 CAin, SCO!CII m 101lT AIlM ~0031 CMn, SC<1IC1110IHl AIlM ~603~ CAST, scorclI :)Ilonr I.EG 26033 CMH. BC~HClII.()N(l1 (:(; 26034 ~6010 ALL AOOInONAL CliAnOE8 -- il;';-~k)NIIOIl--u-'-------;6031- ( ." ,., . ,.., --, ( -- -- , -.---....-.--'---.._~-----.---, I I I I l'ACEIII'AIJli 10064 I I I I .. ,-----.----.~------, I I I I "A!l1I10/111'~(~!\:II)I~______!~00~ I... _=-=-,::_=-~_=-=_-=:.::!. \. J I<1DIlE 101lllNIOllE r ~004Q (.. - - u_ - - ,- -', ( , nu.__.____.____._______,____ I I I I OCII'EIl roOT 10010 I I I I - ;'~~iJS--~.'~m==-~-~=~_=_~Ql= ~ ~ ~ _ _ _ .. _ _ .., ._ ~ IIJ1lI' <lAllII' 1'1'11 F'Xl1 ~6014 --; , f '---, I'll Ii ,AI----...--------'--e5TAT- I I I I .n___.________,______._ I I I I 1'1I!.:iE ox POXI'D I I I I .. . ..--.-.,--.. -~- \... .J ".... _ _ _ ~ .J FxlI'NIlFllCIIAlICH' I ~0160 f- ---- ,( -- , ~Q110 I I I I _ __u._,_..__ ------- I I I I I II I I... J I... .. J 'f 'f- -'~, I I " I " " I I I " I _JI...________JI...________J . -..------- __t-----~____~+ ,(----..---, 1'--'--'-----, I I " I II " I I I II I J I... J I... J ER'0600 mEV. 0/061 CAlilIlOLl. .I'LASlI'll I'XII'NIJI'IJCIlAlIC\F II I' I I I I... ( I I . I \, CARLI5.LE H05PITA.L 111j"MI~~" '''''HI. .dMlllijIt,I'^ I/IlIJI}:I1l1 CONVENII!NTCAllE/EME/lGEN.m'.~""'"" 'PJ,~I{)l"~r I Jr" [)-.'I"f J \ I "'fl.w-tJ" I )51' "''''''OI''-''h '.-] N"""hn-_'_"--:,"---~-' urn''''~' II. .... h,~~~___ Jir.~ rr.tJ),Ill "I. . Il:U---'-,------'--' __.._,_..,__.._~A__ ;.;) 4 ,,' 1'011 NUlllllNU Mi~iE~j[iMEN' . (.('ld('~Ii<'i!',,,,,, ~1[F NUl H,INll IK1CUMI.:N 'MION ~lII1TT I/()/~ '" ,@ (f r!t,,, Il '!rcJ! lid' II ~II l)/ It. 1t1'I': /:-1Ill'o \.-.' tll.. ,ill, l~f.I'l "-:1/1,..(,1 ,t! 1:'~.: ,,-~:;i",~r:;;Y ii1f . ,-~~- " -.-...._....- ...~._-_._.._---~-_..._-_..!-~---_.__..._-------,----~-------~- , ' " 1'1Il,.m~IJ @) /{ d ~(I~ /J ./Y-J,.t" t1/ <Jt~'1 d/;;,-;il_---'-'---'-'-'- jJe d~f!rl~ /f-or:.~~ -1.. 'I'-~ ('i~G.t, -.,,~~~=~==~=-:==~'--=:-~~_,-_.- _"h' It/ I f/ ~'-I -~---..- ---- n.-.------_R____l_. ILlJ;~ Ill\r-;IIIN~ ,)lIDUI I 1,11111 'II j 1,\11,1\' II' ,t ----_._----.'--~_..__._-----_._--..._-._--.-_._-......-.-......_- __ d:~~~_~_~'=~-=:~~~~_=_., ::,~~,>'-'-~~-~~-.,=:~-_~.-. ____~ ~ -'-~'_t- -------'-~~~~71~d~~~-:- ~ /",,-;:::I.ire(.u.{'-C- 11~7'i-J)J . ----,_.~---_._-_.. - ---- - ------- ..-+--- (V/tq-- I,'" ; ~ .. -------->-------~------~~______t+_ -----.t____ .. ----..--.---,-----,------. -..- ...~--------_..~-_._,+ .-.-..---------+.-----.----.. .. _.._._____________.__..+.... __m.. __ . ___.___ _....______. .. _._..,__.... ________+,_____._____. j~'~;;-- 1.1 U 1.1 1I I J -.--,------- ,." . --------.+.__..-. ....-.__...__... 1t!'1)1: N"~II ,I/Hi IIl/ljrj .1Ittlll ~LA--.._\ AA. . - -~J."--I- --I~-r---r-:-~"'- T";fCi~"~'.'~ I)).) 1.{;;~;~~;;.ii;;';;;;,'.;~~;;~,~Il-h -, r.'r.r . :!,f'vp-1-"~-~_ ,)I' ~ h~~/I.f:.~r--ltJ Ll/l.V/",~. vf.,:,_l{.} DI81,~I~,~Nr.il~;~ --i] 'E-;;- .'~~~1r/,;i,;-' ~ , 1\lfi.l... ... ", -r::- Honmn llMl INIY. r~e"OND.D ~~N~ECCIlECK IIIJHnH n Iff A 7.\;'~[i~?IO~h. _.. .-__ ~n~~~ 23~4tS76 D~OUFFER, lllNAIE n. il/~o~~6 12159 30Y ~/N1~rn~"""~~ Elt.{)!")on lliEV ll/lHil A'\ CIIIIIHI" 1I11HIIIIIII tit 1IlIlllh'lIlIh HI'IVI"I'H HURliNG DOCUMIHTATION - ~MIiIlOl!tjCV / COHV~""~tH , "YI"Wh' lUU1 1lf,/'/l1I rM~,.,r CAnE r;~NrEn ( IIM~I LlliJ.JrI;, ~ ;\":3Rdn, TI1IAOt! Nor~, ' Illle: j/ I/s ql.. ~ I WI 111111111 hlnhJ/ Mlldtlllr AIII\.U "-"1\"11 Wllh Itc)()M . li ~ ~ '')- ......, 'I I I Pllnlll) I I I /1.111 I J 'II h I 11',,11, II II '1111/111 VII fil hllllm" ~~~ ,.S'b I.. J , 1111"')/11)' II iJ~lllbll!lIhll)' II PUI.1l11 biJ 1111111)' P ~ II ,^ J( IIp' ...~o ~PIII"II)' tll ri WIU.lIlt hllll I ) IJIIU r) l}lhUf (l.t I rll~11l Ij ~ IJn ('IIlV I filii I) CnllW11 :hlllll"11Jlll'j/llll'l ' , 'l ((i) I L <:IHllllljll~IIIIl'^,lIl1~l; lilli' IIAII' ~lL V \.J.J.IV\sU\ wi {. I...T'<,' \t.\/lt "".., "I H'~"'I"""'" 1111/4 ( '7~ Nlllblllll/'i..lu"I(:.llIHllllllll{ , Chlhlllllllll IlllIlUII1I,lIllntlll II U III II Nu\-'ol 111111111111/11 PIIIl/ 'II 1\111\'111 ~ l 4 n o 7.t I^'il 't'rfl:''''=,.. "'" r. I IA~I r-\1l\..J/CI/(l "'" \ k,d{ deM; ,-r. ffi~ ::'~', J ,"~1 1'tl)H 1'~1 lOft tMil DOH IMil 1}l)H l.Mi' )llH lM;t I)(M 1'~1 .. hOH I J (1)1)1 I J Unlllrn~ I J II.,,, ~Lal!1 Hl'UlJlm II/II COLI)f1 I ;J,.fillilll ri Pllttt 1ll1ll'tlIJIIII (IWonl. I)OlJf\ty II rlllt5-hpll II.JillJl1tllll'd " " \II KIN! Wmlll 1)11 . ml!I\TM~NT IN pnOOnl!BB ON AIlI1lVAL, I ) elllt Down 1111'1) . / 11\111 n t\ItYtny II ()'Il"IN~IID' il,,, t 'J f\,lIwRV,I:l1llollndllll fil rt J~ tJ "II'''' ny, lill!iIJllndw' 1:)1 II. ,\ II IV tinllJHoll _., 11 l/ fil/lJ '-Ulld 80lllllhl !'Iullt (,111111118 I i WI'li",.. '1'r.lImnl 11111"11111 I' flN.'111 , I_..~~'" IIlH - IIIlllln 1 I 11t'l1f'rhl II Monltnf 1l11~lhlll 110'111"" I 16M II ~'IJN<: I J tillltHl1 hnllh) , II All I", - h II 1~1I'1. r \ I J PllJl'itillW IJ"'Pi~II'U I 0111111 Mo"lnl A.....,"."I' I)onll Mll'~' . , I hlJjJqltt- 1~1'''ri)'I'I)/lntl' 11 Cllln"I;pll!1Intll'f)I,5 I' IlIhll'II'11 nnt I ) Vn\llJll lliHI)l1lll'ldl'11 II P,.h'/l~I\" 1IIJItCl1r'llt,.'1 I I "1'1"Pj'r!lJI\ll I J Eln~ hI fUl."m I J Il,..1I11uCllml'llhl' ',I WI'I'''''' "'1l~111l1 ""1'1111 11111111 VI."nl AcllvllV' 1)1) OS. I I With nl_;L4J -~- I J Wilj"J!iqIIlHII' f'1'" II""'lmn r-I'II l1unrllllH UQWII BI)undlllAbdt 11) Iln1pnIlIJIl" ' rJ /l.rll\lll - A&/- 1I11H''' 11111"" _" _ __ ( J OUAtllnnl& ._ 11MI' 'Il~u,- -, 7 --1MI' I ! P~;YCllor;OCl"I,EMOIION/l.1 11!!l._ -n',,^ . INITIAL NURSINO INTERVII!WI I1I'MiOll fOil VI~1l I 11I1AIIMA PMI MFIlICM HllilOIlV I 'MFIlICAI BUBJECTlVHr (Al/8ft 01 hljl")'IHlfilm)' OII'Ia)5tlllllltllfJl5Ii IWhAI Ih1,l1JA11ll111 1111111 ~rlll) " REap, II NIJlIlInl II ~hlllll)w I J 0,,"1' I I tnhOfIll' 11""1>"' II ~I"" I J lilildlll III rOIl) lit u"l II ^111!il1Iu WIUlu'l) I J Ilull/ldllH1a I II :~lIl1l)ltl: II N/l11I11.'I11l II CIll'lUllllllll TI!T/lNUa IITATUat I J WlIhlll rl Yllllltt I J f),1lI YUllla I J Mow UlAn HI Yl1nll (I Nu....I!I II bllltllll 1'll=rdl)'1I111511i "Nt1Hlit"'il<i"A I 01110 It 1.'-.h'''ll..Vcr ()U:P onUt)/n Itnlu I__Mlll Fp(l(ldl 1..-1 Ntlliiii,I:Cll1nt II!illlllll II lnl~nh~., I) Ilrpl'!lill\1t 1.I tJLJlllhhnlJ hlt.mlll." I J MM' ,-- --~~AL-- .,:.:-)_~~;~~;~~~,-;:-2~~JL=:'.~~ 1J,l!"U),'~ ~ [] liiiA(1 '-) l'lIpn1tfllj UIII.*((11l1 U OI~I"nU'p~1 --,.. .C({:_-iUJU~___ '''y- OBJECTIVE! Ph~&icltllnllJl/1lnlion (Whn' YOII All! nhlQ 105M) , - ,11.1_...."l..J iL~~ . !;':...Ji!f'f:;t~ L. 1fi U'..";-{ }, tW ,,\ ?<.- (~"L;:.,,'7..... (Ol1ltlll hlfl,h" h\lll MI)IJ,ht)' lI11pAII'(~ flllhl Vnhmm, "-1t!l'nhnIlPllIl NllllrrJlllplllt/lln (\AI\ r ~rhn"lJf1. hl1plllllld !11'11 Cml! fhtl'lll '.IHllllhflllllll1 II 11\'11I) t;~llllt\"'UIIIV, III1Plllll'IJ .x'i",prllllll I'nlrmUnl fllIllUl"l P'Ilr:I1rHl, All III (-'"Ilt/V, fllltlll1l1rll IIM\11lJ f'mhl!ilp/l. "II III '''''""1.U_~'~'.I'r': iI,l~1" "":6"<" I ~(r (t ""I";I,!i ';1<iN^'IJIIE "1u do-~ y) fw.. .a...6l);.LJm --~--~: L(o"~-w .M,- PLAN OF CAnE, I)",', - - ...... MIIIIlIl\II\ PlIllI?/ll Auwny l.) MOlltlm CnIlJIU\'Al5whlf 61RlulI I J IV I J I1I'M""Il'" r J H-<(\ I ) Cnrcllnc MonlltH I J t;",,,,)' MllfI6WQf\ Illh'51111Ulhl I I !illlntl" PIOnllJlll)na II tilll/llf" PII'(/II,1I1lr15 ,/ !Jfillln !tmtlS Uf) "fTcrJltlllJl1Mnfl5l/1llfl II PAIIl ClJnlln! II POIHIIOIlIIlf elJlll/wl 'rrfl,"PAIQ Illt 1:'Am .U-f'1Jtn1n P,Ilc'lllh,IIHI II FlI1l)llllunl GlJflP'"1 .'-I"Piilij/fl1 r"I1I./lIIII) I J fjll~AJU&lttO-~"~lflJdll)nli I J Olh", ' U 011111I__ PATIENT Pf10BlEM' N,,'''''tl DI"y""'" "11Vl'A~ C1t?Atnllr.n, hwllltrli\ll} /l.1l~IlHV I1I1lAUlIllU "nlllJlflfi, Illp'fr.rll\lft Cl\lIjlnr. Ol,llllJl. 1)01'lft1111111 (1)11I11)11, ^ttml\llIHlllln . (:iJIllIlIIJI11r.AI1oflIJllPl\llfl/1 OUTCOME/QOAl: r )I)I!f;lflll hVIJIFr hlll\l" I'llI'll ~lIl'1i I . 4 . 2 . Ii . J, . O. M ~ N ,jj .- l'J o ~ CllrllNh' lIoNpllll1 ~, IIlId 11"111111 S..,,'h'I'N COt/Ut/T TIJ Ill)arl'l'lIJ, II11HUnlotl 1It11l HKUICIII. TIIIIITHltlT N"III11 ,,( I\I'le'lIlll1\1 I'hYII""'11l 1111, IlAl" ,,( /1<111I1,,,,, Oil' ,. 'n.... _I II. ~tf~, '. ,,) '1" IlIn! _..___,,_._'.._'______ IN~I..____"II'MI..,__., 1, I, (Ill' .. _ . _.___,_.__..,___ A"llll\1 'lJ1 Imho I I O( I 1'11111" O( AlllhlUllJlI thl"I'~"III..llu . 1111 rln I '"l' t I Pill I' l'onr! it hm l'ft1pl i. l' illU hOllp ll,t 1 "Illr.! I h," "by - ...-.-- N;i;I~-i)fii;;!l;i~- l'OIHJttlll' lo ntlllh'I'ill~J or ..lid) ,:.,10, Whl,'1I nh1Y IIlI:l\lltu p)Ul1111J dlAHIJOtJI:1Cl plfJ('t1duIIIU nlld nlldl 1II1101lcol tloAl-III11I1I: IIn Iho 1111111.,,1 "'.I'IIIo1,"!, i'hyull'1uIllu) 01, oLhol' 01 tho houi'lL/lI'u 11I",\1.,,,1 ul"" 1_'llllfJir"n lo hit" IIQ<<.'ltflIlIIIY. )., J IIl1d"l'nI'.RIIII lhl.1 I Ill' pnl'~I.l,.t1 fir III1Hlil..'1nn I'll" rHII~Jlt..y ln nC}t All ")(I\C.~l lIl.'l'IIICft nll,l '-hill: dll1911tJnjo 1111<<1 ll'OIHlllffl1l' mAY 1I1\1IJ\V" . inku of lnj'Il'Y, or aVlllI (jPI.th. 1 llr:kl1owlnd~JIt l'lllll 111) HUItI'IHlt,.llttl ""VI! hOl!1I nHhtu lo Ill" AI' It) lhn lou\lll of 1')(AII11I)nl: i01l ,,')l" ll'lJollllelll lilia-till] I.hill hnupil'olizIIl'on. ]. IJIIltnrnlnlll1 lhAl t (^l Il in "IJtJlclIllH"i', illlllnll" nlluPI'Jollcy OJ' l!xtl'l1ordlll11ry el_ITIIIIUJt.:AIlI.;Ufl, LhAI. 110 nuluJl:ill1l inl JHO'~OItlllfUI ill'#? llfHfotlllad Upoll (I pnli,unl \Jullluu BI1(llJllllJ 11l~ or "hI.! hllU hRlt RIl oppol-1:1I1n,ly lo dil!JCIIlHl 1I1f!111 wilh Lhe phyuiciRIl or otller hltRlth pl'l)r~rlUJ'JIIBl to the lll'llanl'u nntilJtnct.:iolll (Ul 1I.:IIch Plltl",,' hnu lh~ ri~Jht I:r) conUrjut., or to H!fUIJI't <:oll".,nL, to illlY P)'OpOlltl,t pi 01;1;1[1\11'1'] 01' I hf!I'OpIHIl: ic coUru" I Blld lei NQ poLl"I1L willi", il1volv"d 111 "I1Y rO"""l:ch 01: "~p"l:l,"ol1tlll pl:oc"dllro wll'.hollt hill 01' h", (Ill! kl1ow!"d!," /11101 "0111111111 4. J. IIl1dol:otoll'\ th/lt lI1ol1Y o( "h., phy"id,,"" 011 lho "LMI of UllO hOllpi.t"l, Il1cllldll1~' thll ottlll1,UIIg phyoidol1(o) 1101111101 "ho'"" /ll" 110t III1'ploYOII" or "'J"I1LII of Lhll hoopilAI bllt, rllther, lite illdf!pontll!tI1t C'ontt8r:t-rHfJ who hAV~ UrtOn ytllllll!d tho lH'ivilogo of lIBillH l.tn fR(!1.lH1ftlJ tOl' thl! CRtl! IInd lH"ltl1l~IIL n[ Um1.,: pRl1enlo. FutlhlJl'j J l'I1Ul11tt1 thAt "11I0119 tlll,"e who "lto'hl POUllllt. At Lhlo hooplt,,1 ",." II1pdlc"I, IllltflillU, BII'\ olhol' hll.lth c"ro pOl'flolll1ol ill trol11111g who, ulllnofl l'O'!uool'.ed OUIOIWioo, IIIAY bll pU."l1t <lutll1g patllllll cato /10 A pul: 01 I'.h,,11' "dUC.UOII, Sl:ill Ot 1ll0ti0l1 pl<'tUt"A IInd doo",\ dtcull ""I"violOI1 1Il011Itorll1~' 01 pAtionl CArO ,,100 lII"y bo Iw"d lor II,hIC/llioIlBI purpoooo at lor documel1lalloll 01 Lh" dillk,,! COIII:O" 11111".0 /I p"Lilll1t oxpr"ooly r"qllllulo othotwloo, ,>, J rolo/loo CIIRLXIlL. NOUITIIL Irom /Ill reopolleibil1ty 10l' /Ill ort1cloo which J lUll I'IIL"lnll1g or wi II h"vo with 1110 during lilY ot/lY At tho hoopit/ll, I Ill1derot/ll1d thio incllld"s clothtng, 11l'ldgnwotk, I"IBO lllel'.h, IIy.glAoooo, j.welry, malley, rod1o, razor or /IllY ol:hll" itOIl1 kopl: III my po.o".rJion, I Ul1dOl'lltA"'! 1 IllAY depooit VslUAbl"o ill /I OBr.e provld"d by tho hOBp !I'. A I I ollly Ir. thin lfl don II will tho ho"pitnl BBoume Any tBopol1oihillty ror tho flAlokoopll1~1 . r., I hllrllby nckllowlsdg" th.t I hAV" reclllv"rl wrlttel1 inlorll1ation 011 the topkll 01 I'IIL ionl: llight" /11101 Adv/lllc" PI r.ct I VII., DAtil or~Sl'II:"':lJtn' III X r, l.:, 'Y..~~ ,s~-- 1 .. ~..l l...~ SI tlATURI or PIITIltIT C (-1/ CI/I au) (aIQtlATUlII or WITHl8ilr--- (I f pIlI. S f!111-_ in llflltbl" to r:onol!IIt (ll' in ill m1.nor, complete the followlnH I) I'AUOIII: (to B mIllOI' ___, y..aro 01 A~I"I liB ul1Bblo to conoont bBCBUOO), -.----------------,--. ,- (iiXCltl;'TUii.uci,j;iQkl,- lilijilDIMf OR ,-- CJ,OSlnT IIVIIII,IIBLI RILATIV') (aICltlATUlII or wITHlaaT All 011'> (10/911 () (" ) ,.. ~ () PAI'IENT'B NAME INBUIlANCE co: l;al'liHk IloHpllal alld IIpalth HlH'Vkl~H "I i )/" 1',./ ,: ,',I.J 1(...(./ I I I '\ /;(/'I :;lill~/II~1l1 I') I'~JJIlII Ih~ 1(~1~1l\~ 1'1' M~IJI~1I1 11ll'lll/llilll,"' illI.) l'ilYJII~1I1 Ill' M~~I~III~ 1l1l~hJr (lIh~1 JJ~llllh JIlM""Il~~ 1l~II~liI\ IIl1fl/'" I'hlhl..IIIIl, I 1lIllh'Hl/t ('1Ir1lsl~ IIllsplllll liS Ih~ hlllllel Ill' IHedkll1 IlIh"1I111111l11 pCIIlIllIllI1! III II1C III I~lellse Ihc lIeceShlII) II III I IIPPlllllllllle lIIedlclll IlIh1l1l11l111l11 h, lhc l'lsc II I IlIlCllIIC,lIl1lY III' Ihc SlIdlll Sccllrll)' Adll1ll1lsllIllIlllI 111111/111 hI Ill)' prlllllll)' III slIpplelllclIllIl hClI\lh IIISIIIIII'CC "'HIIPIIlI)' III II's .lesl~lllIlcd IC\'lew II~I'II")' rill PIl)IIICIII h'l senlCCS lelldclell, I 1I111hlHl/t Ihc ('1I111sle IIllsplllll's 1I11,1/llr Ihe ph)'sldllll'S hllllll~ IIgelll III SHhlll1l II dllllH III Medkllle l\I' Illhel h~II\1h IIISIIIIII1"'~ 1111 111)' h~hlllr. III h, 1~'1l1esl. IHI II IlIIC 111I1~ 'HiI)' hllSls, 1'111111 Ihe Slldlll Scelllll)' Adll1ll1iSllillllHI, SII..h IlIr'H1II1I111l1I Ilccesslll)' hI 1"Hl1plele Ih~ dlllll1 slIhlllhsllll1 pllle~ss, I 11111 lh~ IlIdll'ldlllll III \\hlllll the Il1rlllllllilllll1/Icelllll p~tlllll1s, III 11111 IIIi1h'Hl/t.1 III elll1s~III, IlI1 h~hlllr Ill' Ihe Il1dll'l.IIIIII, hI Ihe lel~lIsc Ill' Ihe IlIrlllllllllhlll/lccllld, I III1<1Clsllllld Ihlll 1111)' rlllh~ sllllell1el1l III lellleh~Illl1lllll1 kllllwll1l!l)' 1111<1 11'1111'1111)' II1I1<1e III Cllusc,l III he 1111,,1e rill IIse 111 <I~lellllll1ll1l! Ill!hls III Me,lklll~ h~I1~f1lh III PIl)'1I1~1I1S 11111)' h~ plllllshllhl~ h)' II f111~ Ill' 11111 1111I1'e Ihlll1 $10,000,00 III II lie )elllll1 plihlll1. 'II hlllh, le'lll~hl Ihlll plI)'lIIel1l Ill' IIl1lhllrl/td hell~f1ls h~ II1l1d~ IlI1 111)' h~hlllr. I Ilssl~1I Ihe pll)'l1lelll Ill' IlIpllllelll III (lIl1plIllelll hmplllll h~l1efllh III ('lIll1sle IIllsplllll rllr Ihllh~ s~ll'lces plll\'lded h)' Cllrllsle IIllsplllll 1I11<1/1l1 I IISSI~11 Ih~ hell~f11 pll)'lIhl~ rllr ph)'- sldllll sel'\'k~s III Ihe physklllll, I c~llIf)' IIHlI lh~ Il1r<llllllllhlll I!ll'ell hy III~ 111 IIpplylllg rill pll)'II1CIII III' scrl'lccs IIl1del llll~ XVIII Ill' Ihe Slldlll Secllrll)' Ad III rllr 11I1)'/lIlIlllhel hell\lh IIlhllrllllCC 16 cllrree!. , \hIT~"~~;iifl~i;.LJd' - m j (,.:\ : t''- .. /11.f fit, . - 6sN-----'-- -------'-o.;iii'----- f\ri.iiiii,i\'lfif.. roily irPniio"i vlllI"j.. ii, iii,;n - ---- - fii,iniiiui!ihij,-- ------'------..'--oriio------ ilmlji-;;f1P';'801;~ -fiiUI'nfIJ;~l- .--..,...---- ____h___ -.._-.~..--------- (II dllll!llml hOIl1 p"1I11111 or II fll1lhmllri n minor I Dolo ;lrij'~lln f1"ihml'rfllli.j nni p)lUll' .~. .~..'__._____...~ . ___.___.~_._.._.___ ._.n__'_'_'___.._~__'_."_ ...-..,- ..-....-.....----..-..--- , -,' C ' IJ,',/I (i'!J__ WII,;,,;," While Copy - He"lIhcBtB Dilling Conory Copy - Medical ABcord" ( /lnr.lllatV Depa,'men', ~Clli'IIHI(lIII)Hlllllll ~ IIl1d II(IIII!" lil'/Vit'll~ . 'I I ". 11 ~r,~"" CONVENIENT CARE/EMEROI:NCY REGISTRATION 111ol1"~-n~-11~JitV'11f4I1/rl -" _ftJJillr.JZ\111,-I9JJ] fl.'. ,I.. .....j'I'.L/lI:.J,g"""rllf - . -." 11'1111" I "," -1'1' '-I''''I'rrl''\ll]''''I''''mltIllJllllR- n2!11it$. .1116/% 1:1.41 MIIII ~I ~OIOI 0/ M 2300210 1ViT\~TII'jJ1lr.. lh111lllhN ~""~"tjlfl.,lI h,. I")~hllj -jl\if1i1\rm-- 1111 I EI.IIII I'n I I II (,I'U, 1:1.:10 1Ul.WlJmlWU,1\.~I7I"lI'i!IY,n/l",,,u-('rI'r' 32"1712'-'--- rllilll .1"illll>\,',11l ' ---- - " ,.. STOUfFER, LIIRRIE n. 3QY F M " fRnH~LIH CLIIIlIlHn cn 21 "III1D BT 031:l:lltlQ ',IINnnH n""Hl/1 101i-II0-11i99 1l1l1~~EHIlIlIlRII, rn OIlIPP["OIIlNO, pn 172117 1Iij!r/ll\ll1'1X'n"r~mnw:l11'n-:r:nr"j,,'t'r1'1' IT3'-IT1"- IITnl/FFER, JEfFERV L. :II ORflnn liT ;l~JMJil"~1 r.IHi,j:,1I1 --- -. --..--.. _u___._____.,...............____._~__..._.. t:nNlIIIU: IIYHIF.I: " n IlnM 1000 cnRLllILE, rn 1/01:1 UlllrrEHIIHIIRII, rn 1/:1111 m.JJr -J.Tnirr r -lii~vjf.~ nn Jh"'iT- r~-)'" Tr;'lj;1- -_..~-._.__.._-~. - --- - --. ".-..--.....---- 11i~-Hi-litl:l!j 1t1:l/f!-r.IlOnn--311 J-"--- III1DHi~~IiMI2!1 :lIi I UTIIl/FFER, JEFFERY L. rnlll,-,n~-;H;;ruY -. ..- "--' ~ ~ ....---.- UIIIEl.UH, VIRIIIHIR C " I n !I:12-~!I77 I U OJ--'----- 0:1:1909000 0:1 -..--.~.. - -.. IlJfili;'AlM~-';I>>~T'-.--'-- _.u___+___~~.________._~~__~_. ----11111 --gn-:mrr.." ~IIRLnHTZJC~, ROIlERT L FREEMnH, MILLlnH . _.-. .- - -. ..----..~--_._~-_.+------.._~~_..-..... nHllnl/LTEU IlV HIIRlnHU IIJTE R flll/M" rnlH HEC~ nHU NT RltOIlLOER - . -.- IllllEr VI~'fl 20700 2~710 20720 20730 207~0 (I. MH) I Vlf;11 CI. A!m II Vllm U.N,!lIUVI!,1J Cl. A!)!i IV vmll Cl.AStiVVliifl 207&0 -__..________ . J__ :;:::~:'::~::::::::'~~u n~~::: MINOfl t'lJ 111I1F. EOS II 1 MFfJIIIM n1JflJIII' EOS 0' MA,IOlll;I)IlIlIE EOS 03 INflJlWION EOS O~ IV SI:1LJP !OS 00 CM1fJIA': MONIIOfl EllS II ['f1VIC "'^M ens 1~ NI JI10 ~E J.lIP EOS 16 CMH, !)COIClI mlOIH AIiM 26031 C"~'. !)OHclll.nNcl "'1M 26032 eArH, /;CO!CII nHOlllIU; 26033 eMl1. /;1) )If:lll ()Nq I Hl 26034 q.;J3,~_'i)'L~1O q/,:;.O i::'_C)lpH~ _ 2l\li7& All. ADDITIONAL CHAnolB Efft7lf.f) 2~03 7 ( . .. -- _u , i' ,.. -- '.. 0- \ I I I I 71lOO~ I I I I I I I I 2611110 'u ,_ _, ) '- ..._ __ .. .._ J ... ____ ____ _ ___'_~_'___""_ ._ ____.___~.______u~....~____~_~__ 200~0 ( - -, '-, (' --- .. '- - .. .. --, - , I II I 70070 I I I I I II I 11000 I .. , . . .__ __ __ ...J '- ___ ,_ .., _ .. ._ ,_ .. j ~n074 , -. ,-- :::-'-;-::'-:':: -=-=--::-~ (--;'-=-:=--:::'-=--::--:::--,=,:'-:.:"~ UTAT 1 I I I ....____u_ I I I I rUUiE OX POMEO I I I I ._.___....,__,_._.u__,__,_______.. I.. _.J I.. .. __".. j rX1ENDf'IJ OIMIGF' '0700---=--=":- ,- _____n__._ ( - -, -, -- "\ i' .. - .. -. "\ ExtENDED ClfM1GEiI ,ono I I I I ______________.__n..__________, I I I I I I I I I.. 0_ 'u '" .. .. _" _o.J ,,_ .., _, __ ___ _ .. .. j .___n __.___ _.,_____+ ~_____ ...___....___ _____._________ _~_.________~___._..._ -- -- -- -, ." 'n -, -.--, -- --, r -- -- -- --- .. ." -- -- "\ r - ,- ,- -, - - -- .. '\ I I If I If If I I I If I .._. 'n __ ,_. ____ _, __.J \..._ __ _', ,-.J I.. ,_ __ __ _, '- " ) . _._________.._n..___.__ _ _ ______ _.._..____._____._.__ ._.__.____.__.______. .. ,.. -,- ,-, ,--, " .- "\ r - .. .. ,- ,.. - ,- -, i"" '-- -- -- ... .- -- - , If If I If If I I I If I ) " . .. .__ '" _, .I~.. ) F.IHl500llIEV lI/1l1ll eM! nllll.l'lMIFl1 1I,I'MONflOIl IW:I'IlI'^'Hl (\M,rn()/IU:Mc) ~j\ Illl: I<IIHlF. 101)IlNIlllJEI IX:I. I'FIl rnOl rrnr, 'IlJl1r IMU1F \'I'll rlXJI 1'1.1 r,IM r I - - I I '- .... (- I I I \ STOlJFFFH, tOHlll1: A MH /I03non t tI 1131 10013 6uon 011~ 32 HISTORY, Thl5 Is 0 31l'yuoI,old '''111010 who 111(1sonls 10 Convllnlonl COIO wllh Onlll/uty 10 Iho .IOhl Ihul11b This llCCtlllOd ulullor lodoy when shll was nnllulllld by ho. husband WhOll 010 WAS Ilylllg 10 lel110ve sOl11e lUlnllu.o "ol11lholr houso AlloI Iholr SOlllllllllon During Ihe ossoull, Imr hllsllond lolchod on 10 her IIOhllhul1111 wllh his 111011lh IInd whllo sllll WOS lIylnO IlIlIulllhe Ihul11b oul or his 1110ulh she sl.olned hOl Ihul11b Bho 1101lced Ihol sho did b.ollk Iho skin wllh his loolh, how/wer, Ihe" WAS nolo punclure Wl)lInl! Ihlough \llIt skill. jusl 801110 sl:uhl bloOdlllg 11m \l1I1111b Is pu\ly now bullho.o Is no .edness, no IIlcl01l61ng SOl0110SS N'lnOIJlOVns':ullll JYl11plr11118 dl61nlly Bho nollc"s S'1111e sOIonen OIound Ihe 6houldel olso Ilol11l1ylng Irl oelllwllY bul 6ho hilS lull I/II1UO 01 11101l0n Gho slnlO8 Ihol sho wos feollno 111111 0lholWl6A No 6Yl11p\rJlllS of dUplossloll Iluos nol wo1I111) sou n CIlsls wOII\~r IIIIhl6 \11110 No olllPl ",OilS '1llIljUlY Nil che61 pnln No ohdol11lnlll pllln No 'llhor jolnl 110111 No olher skill conlU610lls No hond I11jlJlY PAST MEDICAL fHSTORY, DOlllos slOlllllconl pnsll11odlcol hlslory CURRENT MEDICATIONS: NOllo ALLERGIES: NonA known PIWSICAL EXAMINATION: VIIAI 61gns lovllol sllghl olovo\lon 01 Ihe blood prossure end she will lollow up wllh hor fOl11lly d'lclor for Ihol The IIIsl01 Iho vllolo ore 1I0rll1el Ooneral e~B,", Blert, Irlelld, Iy lerrIBlo III no OClllo le6pllol0lY ,Jloll08s, Willi dovoloped, w"lInou/lohed, well hydroled Polllled olThopodlc e~nl11 01 Ihl! Ilghl 61ltllJlder shows lull rOllge 01 1110\lon Fullll1uoclu olrenglh wllh reolsloncu No heul, lednu66 01 nr.chYl11osls In Ihnl oreo No pOlllllolldelne6s 10 Ihe 1I0noo The rlghllhlll11b ohows 0 6111011 6clnlch dO/61111y olld vQnllolly bulno brooking IhfOUOh Ihe epldo'l11lo The Ihlll11bls qulle swollon No ecchYl11061s She hAS docronsod ronoo 01 1110lion duo 10 Iho swollln\J ond sllghl I1lJlllblle5S 5ho 5111106, hullhlll16 golllng beller, Two polnl dl6clllnllmllon, cnplll",y ro"1I16 nOll11al No IIgol11enlln510blllly TholO 16 50l11e lel1doll106S 10 polpollon 01 Ihe bono pro~li11ol pholol1~ 01 the Ihul11b EMERGENCY OEPAIHMENT COURSE: Tho Ihul11b W06 x,rayed which we6 read os l1egollve for ftllcluro lIy Dr KlIIlAnlllr:k AlvJ I11Y6011 Augmel1tll1 GOO .11g glvel1 ond sho will conllnuo Iholevoty olghl hours wllh food Thll muo W05 clllol1od wllh Retodlno 50lullon ond Irrloolod wllh Solll1e Sho 6hould keopll 06 sllll 05 p0561IJle 1111111 6ho 16 rocheckod A bAndage W05 oppllod wllh Oocllrocln Follow Iho wound 5hool, ol1l1blollc 6hllol Thorough coul16011l1g onlhe problom6 Ihot cOl1l!ovolop wllh hUl110n biles ollhough 5ho jll61 boroly broke Ihe skill 50 I dOI1'llhll1k Ihollhl6 Is oolnu 10 bo 0 probllll11, Lul we need 10 lollow up VIIIY c10601y I<oep II elovalod ol1d reslll B0l1e1ll5, rl6ks, Al1d 0llotl1ollv05 werll given Sho ul1derstonds ond oureos wllh Ihl6 l.eoll11enl plan and Ihe risk 01 nOl1col11pllonce Wrlllen ond ornl ;,16lrucll0l1s were glvon before dl5chorge The ca6e WA5 rovlowed wllh Dr KUflal111lck ond Lorrie ha6 /1IJ lUlther Qu06110n5 DIAGNOSIS: 60111166ue COl1luslon ond slraln 01 Ihe rlghllhumb, 6crolch Irorn 0 human bile 10 the rlghl Ihurnb NRE/br 0, 1111611996 ' 02 ~9 pm T 1111811996 Nelson Richard Ehly, PA,C I~ 1 ~~1'^ { -1'k- , Pago 1 01 t ORIGINAt CARLISLE HOSPITAL ~MgBggNgYR99M_Rg~~Q ~1'IIIIINIIIII'IN/l1l1I1 ~, 1I11.11I"lIllh H"I,'ll'I's NURIING DOOUMENTATION -1:M~IlU~t/CY I COt/V~t/JI[t/1 , '11'fl' ""I, )W/lfHM~'H CAllE G~ HE; IIM,'I _ V <. (hI ilU I .l.. I r '.1, "UAO~ t/01~1 1)11111: IW I!,. , (' 1 J' It',!l'.' ',1.111,., ,>~.'11." r (1.111\,11 ""II\I'd 1111 11/)111._" 'U~II ,'.. WI ,1~ 1.- 11/'111,.,')1 1)/'1).-'1 Ill1lh IIPlIlUlJ Vlltd !-jl,lWi IIIJI I !~, I t. r,'" 1II'jlll,'I)' II ~J'''\'IIlI'lItlltl'l) Ill'ml'!ll p A'~' II /..cJ IIlll/o/II"\' I II'JIl"II) III rIWhl'I'hlillll llfillll /llll/l'ill Ii /V' ^ /) ItJ ("Illl\ 1',111' 11.',11111'11 rhll." I I'II'plllllll /I. L' ft'~/' .-IJlIIII III 1.'IIlU:j\'lllljti 11MI OM' It'. ( . Ic,....' ',l.,.,f " ~.. ,:.:.,~ .. ,. "" /L",.I."",." ',/(1 r "......,'"1 ')/J-a./r, t II,'"~, Ie 1" ".,J. 6..." ,,1.1.,11..-1.., ~ '7,.(1_<"+ 1'I,.,r ::~,'I (}tl~I'I.)1 !))/lII:h"llfi ,.,l}\.' IJ,,'t.' 1~'1 '~..(.r..1J~'(~#I,_", M~ IMil N"llilll11 /1..11'11/1('1'1111111'1111, Ill)"-l l;hlhllll1lJlllll1111WlI/HIUlllti 111111) lMil l/IIulllll'nl 1'1111. In /1.11'1.111 l'\Ilt-1" I ~~I )llH I ~~, l)1'H l ~'l;' 1}l)t'1 <'6' HeIH IM,I /'HIH I ~~l II/H: J/ rt " l l 1\ l! " " "I . . TREATMENT IN PIlOGAeSS ON AA"IVA~I II I;PIt Ill)'hll 111111) "1111 1.1 ~tt'r\lIt I) 0'01,1' NnJ'ifll fll'" ....f. , {I "11''0'10> r"dollndll,nl ~I..n I J /l.1t'hAY. NfllIlJUnrhllnl t;I/" II IV !;d'lllllll !ilh1 LIJIIJ' OQUndl1 1101lhl ! 1,'hllAI ",'i/l. Il'U 1 lljll..~ IllImll'" WIII'I',,, ""H,'I liniN IllIn""1 WI''''''I' "h.m'l 1'111,11" Ill"bl '."" VII".I /lcllvlly: 1111 (Hi 11'11 ~,"i~ " 111'111'11111 1':,"1' 111'''1'11'1' W,," IiIAHI" W'II"'111 <llnHI~~ . INITIA~ NUASING INTeAVIEWI ""Mi<JN I 01' VI~1t ",1'1"/1\11# ," Millie^, flMil t.4l-"llIC/l.I. HI~HOnY _ (AL '~IJ.J!,-.Jl./ pULse: Ilt-1I11111'!11I 1,j.rIJIl C9~0"' "(\111111 II P,111t II hl"I/I,111I II WI'lI~ 1 11l1ll'~)' lllllltill/III II ,11111t1l111 "d III ,1)11) 1'1'11'1 ,'/ ,- I (,II I Illlllnll r r (1111\11)' 111)111111 IIUIIVIlI II SKIN I 1~"WIIIIlI 1~'(\"1 11.'lllll II t.IIlHl/HY llllm,1l "fillPI 11)-t'~11l 01111 II tilljlllllW 111),"'11 1 ItullUlIIl1 llllllplll I I f~IL1'h II Shult)/ I J/hlllllllll Wh'~II'" I J Ilt!llIlllltUlti 1.)1/11 I'IIlHljll! Ihl'I.'~Il\U II 0111111 JlAtlENT pnOBlEMt NWfifl111Ihl'IlIlIJ!j16 i\1I'.....'fl)' Cl,lntfllll II IllI1Ue(h\'fl /1.1''''11)' Il")flllllp!I l:nlllHl1fi. hIPlh!('I\,r (:m,llrl" ()lllpl,1 IJl'nlHlfi(111 (t1t1lll)l! Mh/lflllllllfi"I l:ollllIlllJl1llll1l',llIIPflllll(1'1 (;"IJllllJ. 1111111111/1\111 r:hJllI Volt,nl', ^'Ir'IIlIrIlIH; III " On!! I: H:hnl1l1ll. 1111111I11,.'11 II)plJlhmIl111lIr,IVI"II "'I IIIII'fllnl1 Pnlfl,lIlnl h11111)' Pdlllltllll I<Ill),^,lftllw'I)"III,1 Ilc),IPdll II "'".llH'dli II CI/I.IIIU)l4I1 TltJANUS STATUSI 1,""'Ii,1l1l1l r) 'l'1I1t16 II hili 'I'1l/III1 I) Mill" Ihlltl III Ylllllfi 1 J NII\.'l" 1111111'11'1 / II h, "."""'6 f) , 1',1 1 tIIJI'~I' ~,I(II'" 11111' / I." J. ,I '" 11'.., ,,_.f /.(,1 u. II '. DAUGSI II MIlIHln, Illl~Ullli JJ"IIJ II O~~III.IIl I' MlIr;~ I J N~t''M,tI I I !~llltllll hllllllllldl/llhllllj''''''''''-- II Mil" II ,/" MeniAl AUltIlIllttnll IJI"l'INhu'l J.,1-1\il-1"I'/'III'l 1111ILJI'Il',lr'nl I J "1'f"I'~I~" I I "'1~'ldll'lI' ,~,., I IIIII~t!llh~ . .\11110.111\/1 lIow.1 BlIlln,ll'Mull II/l.rlll.ll (11I)pl) I J II)PIH 111)1'r1'llllll'Ii 11"'1111"1 I I ('11>01 f-p'~I'I{\I'l'l~lJ~ I J VIIII"" n~',)llIl",h"J 1 Iflj~l~lI"lIh'H II !',ll1i1lIJli\tl~'M' 1'll'lllplIllIIII liME l'f.1<.' 1 I jJ~i),C1I()SOCl/l.1 I-.MOIION/t..l BUIJJfiC1IYEt CnllFI1 nl h1lwyllll!lol)' of P,efWlllllh'I!IUlIWllnllhl! IlnllllnllnU6 )'lJul / ~f'>t'1 II II,Nnlll'(lI,(111111 l'sd,"\1 I J 1n1~.IIMI 1I11qwMI\n I J Mllllll:hlll} r~lt:~~IIII'I__ . U Dl11ll/nul)' ,_ ._. 11/1.h/Af5101l 1'111'11. lilIES I, . 4 . ~. . t, . " . fie 'Jl'lllll!j-, UlflfAd ( 111I'p/tIII'I' rJ 111/(11111 II fJIP,llltlll'nM ,~ 1MI' ~ ~ ~ ,- ._~. --......~.....,.,.,.c-- o P~AN OF CAREl [) '~IIII\lnlll Pollonl /l..lIwny (J MomlOl Cntlllovnf5rulm 6lnllll\ 1'1 IV IlllI'MOI"'o, r II:kG U Cn/lHIIC MOtlllm LI SOlo I)' MOfl!ilJll!6 f.J !111filtlllnI6 I ) 6111r:I(h' I'IOC/IlJllIHlb II S('I,'WJ) F'lel'(lulll)1l6 r I Suh, f1n.16 Up I I CiJlIllmlMI'l1I'illlfl6 r) Pllln Cnlllllll I J P051110" lilt CllrHlml ll'Pfilpnllllm I; ~Iltll l.J.f..p1nlll PlnnldlJII!6 1 J-~nlMIIl}I1AI SUJlpotl I )-Pnlij1tll "'AI"/II111) n HI~1f\ll} Inl\!tlldll)1l5 I J ()U1I!I II ()Ihm _H' /' __ _', '. _ __ _____m__ O~JJ;Cl!Yf,: I'h)'5Irnll/llntlllllllnn IWllllI y')IJ Aln flh!r:t 10 1'IIll!1 lr .Jt'-r'r~' ..-t.~a~ '_j __ _._ at' ) 1/\IJ_..t.."._ ...J_ . 4.,,,....(/ -f"''-'-''~ -, L'-'l-.. Mnllllll)' hlllll1lfl!d N,J,lrn.l1pllnnl:l1 Snll CIIlp.lIllllol ~~In 1I,lp\lI'ly, In1p1l1tfld Ihl~""tlll"l)U!fi~. AU 1/1 II""III? 1'1"h,611)1I, Aft 111 l)U',nl 1/- (,' I 1/( ..,:_ ,/.I'! / 1:/ / ( . / lLe. , L '. . OUTCOME GOAL: r ~/llldllI1 hy llu'j,'I1;Il'JP tjt JI1~;1 ~; ~;I(ltj^ I LJIH. \ ~ Cal'li:;h\ lloHpll.lll and lll~llll.h Hl~l'vk(lH PATIENT'S NAME INElLJI1ANCE co. , f ,,' / " I " I I " :;11I1~1ll~11I Il) 1'~lmll Ih~ H~I~i1~~ '.11 M~'Jj~II' 1/JIlJIJllIIII<l/J 1I11~ I'jl~IIl~/JL.l)LJ~I~IlJ~IlJ~,uJ)Il/!J" l)lh~1 IJ~lIl1h IIIM"i1/J~~ IJ~/J~/J!~ l!liI'/lI1 I'hHh'llIll, I IIl1lh'lIl/~ ('1I111sk "'I'plllll II' Ih~ hllhkl' III' l1I~dklll 1IIIllfllllllillll pcn,IIIlIIlY hI 1lI~ hi I'cl~II'~ Ihc 1I~l'~~"")' IllId IIPPlllllllill~ 111~dk,1I Illlllllllllllrlll III Ilw I'hl'1I1 1111~I'I1I~dllln' Ill' Ih~ S"l'I 11 1 S~l'lIl1l) ^dlllllll~llIllll1l1 IIII1L/1I1' hi Ill) pdlllll!) Ill' S1lppklll~1111I1 hCllllh IIISllIlIlll'~ l'1I111111111)' Ill' II', .1~,IYIIIII~d Il'Ikll 1I11~lll')' lill PIlYIl1~111 1111 '~nkl" 1~lld~l'~d, I IIl1lhllll/~ Ih~ ('1I111,1~ III1,plllll\ IIlld/lll' Ih~ pll)~klllll'~ hllllllY IIY~III hI ~lIhllll1 11 "'111111 hI M~dklll~ Ill' IIlh~1 h~lIllh Imllllllll'~ '111 III)' hdlllll'. Ill' III I~"II~~I. 1111 11 lllW 1111I~ 11111)' hll~ls. 1'1"1111 Ih~ SlIl'I 11 I S~l'lIdl) ^dllllllhllllllllll. "II:h 1111"1111111110111 IlCl'C~S1II')' hI l'lllIl11k'IC Ihl' l'IlIllI1 ~lIhl1ll'~11I1I pllll'~", I 11111 Ih~ Illdlvlrllllll III 1111'1111 III,' 1111l1l11l1l111l1l/1~l'lIld p~nlllll'. Ill' 11111 II111hllll/Cd III C'1I1~CIl!. 1111 h~11I111' Ill' Ih~ 1IIIIIIIdlllll. III III~ l~kll'C lll' III~ 1III'IIII1I1III1Il/I~l"'l'd, , 1Illlkl~llIlld Ihlll 1111)' I"I"~ ,11I1"III~llI III' I~PIC'~llIlIlhlll ~II'lllIllyl) 111111 \111I1'i11l)' IIIII.I~ Ill' l'1I11~~d III h~ IIl1ld~ 1'111' '''~ III .kl~llIllIlillll fIt,IlI' III M~dklll~ 1I~1I~llIs '11' IHI) III~III' 11111)' I", 11I1IIhhllhle h) 11 f111~ nf 11111 1111I1l' 1111111 $IO,OOII.O!l1l1' 'lIl~ )CIII' III 1111"111, III 11I11h, II~,,"~~I Ihlll PIl)III~llIlIl' 1I11111'lil/~d IICII~fll, he 1I111.1~ 1111 III)' hdlllli'. I II"IYII Ih~ l'IIlIII~111 III IlIplllklll III Illllplllklll hll'plllll 1I~II~nl' hi ('III'II~I~ ""~plllll fill' Ihll'~ ~~I'vlc~~ pl'lIvld~d hl' ('IIII1,I~ 11.lsplllll IIl1d/llI' I II'StYII Ih~ h~lwl'Il plI)'lIhl~ lill' pll)'" ,klllll ~~I'vk~s III Ih~ physklllll, I ccnll')' Ihlll Ih~ 111111111111111111 ylv~1l h)' 111~ III IIPIlI)'IIIY 1111 IHI)'IIICIlI Ill' ~cl'vlc~, IIl1dcl' Tille XVIII Ill' the SlIl'I II 1 S~l'lIl'lll' ^.'I Ill' li,l' 1I11)'/III1I1IIl~1 h~IIIII1IIlSIlIllIlCe Is ClIl'I'ec!. roilulif" s"Jliiiii"o -- I ' , ' I ' I, I I , I , ,- .' I........ .ssN---------------'-.-5liIIi-'.---'--' n"ii"iii'.;lhlop"i iy ii P"i1,,"1 Un'~)'",i;slijl'-- ,. -----.-----i1"llill..)I;61iF-------------5i~o' ji15llma-p;;,i(jil;"ri"si(jimiiJ;o'.'-" ..--- --.----.,-~--_._,--_._--- .--.----~-----.Onlll---.-'- III dlllOlell' 100111 pnllelll or" pnllenll. n 11I1110r I Hon,ic)ll-Pnil'l;,j'C'(II-lltlllo"'6i{jll'--'U' -.-.,-. --------..-------.--.-, .-------..--.--------. Wllil(~Aij ~- II I ,( .. . I t...", ~ ......-..-.-.-. _.. U~___"_"~'_ __....__._..______~... '__.m."" .....______..._~__._ Whllo Copy - Hoellhco,o BIIIIIl9 ConDry Copy - Modlcol Rocord. I Anclllory Oopotlmonts AD 1026 ( I/OG) ~ ('11I1I~h' 111/,11'11111 ~, IIl1d 1 11'1111 Ii SI'I\'ll'I's CI)IlBllIl'I' 'J'O ItOUI'/'I'^', MI'UBQ/OIl IlI!lllcr!llY7~_ ^Ill.l Uilll1" nr 1\1" 1"llldlll'l Plli"ll ", "11 II 1'-' "'I IIlll.. ll' ^dlll)tlrJlo!lI 1k:J ..------.-.---.-------.----.-- '1'11111/1 ,_ __,___ I N>ll ,__,_,11''''' . l. J, Ir.n _~#JL'-Hl:!1l-.o1 f!rt!J Nlttllr""'lllh'lIl ".J1ll1HlIl l'(j ''''1'''''111.,.11 Illl"11 -,ll',', Will"" 11I<1)' ll1dllIllt Il)ll'ltl" .11,J~"ll.ltll,(' 11l'l)'.!edlln..Ulllld /l1I,'1l II\I'dll',I) 111';IIIIl~111 JIB Ill... 1111111I..j .1111'1101111'1 ph)'1I1r'I,I" III) III nlll." nl Ullt hnllp)tnl'u IIU,dll',11 Ill,., f rO'_lIltJld,'1' 101m n"n-n'/oll NIIIII, II' .\lIlhUll",1 Uq'II'Htllulhr /III' f" I 111'1 r II~m II "'Oll.f II 1"1\ ,",'I I/I'J ,,/I !J..h~ II 011 1-"HI~I'l'I"'.J 1I0UPllHll'ill", hlllnllY ,J. I IllldtHIII.ll1d 111.11 'II,' 1'1....,1,.,' '" IIIl1dlc'1111' iUld IJ'"'I''I)' In lint IIIl tl)(jH:l IJctUtl(" iltllt Ihill cll/I~JI1,.ltJlfl "lld lll',Illll"lll 11l.lt' IIl'J'II'J" Ilnlul of 'IIPH)', 01' Ilvnll dni\t:h. I IIckIlOW)ftd~IIJ I hilI 110 ~JllaljJlII:IHlI" hll'JP bn~~lIl1lol,tl,1 I,' 11I11.", 10) ItI", IlJtHllt of ftXi\lIllt1i1l101J III ltOilllllfJlIl dUI'UIIJ till" hl1l1pll i,ll ;'ill111Jl, 1. IllId~I'IHilllrl l-h.,1 t (AI 1t)1I I'll/II ,'111,11 t', ,IllIWIIl t'111"I"'III"Y~)1 ,.>:~II"I~)IdlllilJ'/ <;_'1., O:'IIlIIUl:fllI,'flfJ , Uhll III) "III III l 11111 I,ll "1""",11111111 ill" tll~II';-'l'lllf!I.llIpl)tI., p"l1r:>lIt IJII1'"Utl IInd lllllll h,' III ,'hn 11'11_' 11.1.\ illl "'f'Pqlttlllll'l lo diUClJlIU thl!ll1l wlth thl! pI1YOIl:).lll III nlh"1 "!!tnllh pJ'Oll!tIJ010Ilill to th" pl1l:1enLln 1J4llntHL'tiOlJi f/ll Io:ilch pitll~lJl. Plt>j:r"lfl",f 1'1' hjW I II,., "f'.tt,. " I \'111' I,> 'I. ":I_I!1j11 1"'Il!"'1I1 (','\11 Iii', , I .11111 ""'1'" '/11''''11' 1'1 1111'1 1(') 11-1 1';11111111 '"JIll I'" IIIV01Vt'1rl III 1111~' leUPilrdl 01' ffXI)IJl'lllUHIlill 1>11)1"111111" wlt 110'11 hJn 1;1 IIf" rull kJlowJlldqp. find t'()IWftllt. ,1, I IItJdHtfllilllcl 'h.II Illilllj' "I 11111 I'lIi'II\"IIl/I/! nil Ihn rll"fr r~r l'h)(1 tJ(lfIPlll,l, l"..ll1dlllll 11\,.. iI1tt!'IIr1HlfJ 1"1'1'11"1'111101 lIilllll'.1 ,tl""/", ,1I" IIfJl 1'1111' I q','I'IP!1 ')f ,It/nlllll (.r 111~ 1\'1111,,1.11 Illll. I/llllPI', AI'" IlId"Il"II''''"1 ""1111,"101"10 ~'Ii'.J h.tVll b'.wn ~"'illltp.d tile IlI.lVl!'_,qn ~Jl !JUIII'I 1111 f:,i('jllll"t1 f.n III" "iI'''' '"lo1IP>,ItIll"III' 0' IlIp'l" pAllulJln. rUl'l"htll", 1 l"l!ll11Ut thnl illllnll') 111'1111' who 1111'-'lld P,II'II."llltI .11, llllll 1I0HplLf1J. i\1~ lIIed1ClI1, 11111'11111'1. fillet Olhf!I' hfJnlth ("Ill" 1>"'IIIJlIIII,1 III 11"IIIIII~' wh(). lIIt)II"" I~{plet"(.>d l)\h..nWltl(1, IIljl~' h..! J)J'UIlP.llt. ,II.II'I.IJ'] JliIllent Cl1l'e 1111 .1 Pilll '" thPl1' ,HhlciltlOIl ~.I III el mnll"1J p1('llll'l?/f illld rl.,)f}r"l cllnl)1 t"rtl"'Jlrrl',~1\ 11101111 ,n III" IJI P,11 )"111 (',11'':- illun m,lt' I),~ llrl....,j rill '~"IJ"<11 1t)lIdl ~'III'h'jI"1I 01 t~lI d()'.'\llIlf.Hll.,lI011 q' I h.. 1'/1111',11 ('[Jlll-fl.t IllIleuu il Pillll:"lll ('lIXPII!t1~J)" "I'lltt'utl! ,',I hI1I'Wln..., '~. I )flltl.HI'~ CMtr.,XSJ.,1 HOSPITAL ('~~1Il nil respollnibilHy tor 1111 Utllr.:)1J1I willi'll I .1111 l'ptnlll11l~J 01- \lo'Ill h.1V~ ....'It'h m~ rjlll'''IIIItlY nl:II}' Ilt l:h" hORpHnl r IllHhl)ntAtl11lhtn III,llId",1 c}llIIIIWJ. 1>1 Id(Jf_lwull<, 1,11f)~ 1'~'~IIi, "~I'II,I.l/1t'I'll. 11~'N~lt~'. mount', uldl(l, 1"'JJI'll 1111,' 11Ih'>1 11'1111 1<l!pt )11 Ill}' P'WRl1tlF1QIl 11111'1")111'11101 I m'l:> "J,~.)(fI1t Vlllul1bleu 111.1 11""t pIII':ld,'" 11\' Ih.' hlwplti1l; nllly If lhlH 1r1 d<'ll" \<-"111 tll,> ll"IlPLlil1 /lnfH11I111 1111>' II!UPOlllllIJllll,' "11 lit,. 1M' ,..1'.1'I'p III~, (" P.11 I '~f1' I It'-'I,,..I:',' 11"1;1: '....'l~d'f,' lIltll I hil'JP- IN.'oived wnLtftll 1I1(lJlllIil1lnll 1111 I Ill' t "PII'II lit r~ 1 "till: ,'to,i r,'I'J'''l'.'f~ III lOr," 1 VI'!l Il"'~ ,,( )j~'''oHlIl'~'__~__._,u__.JL__jl,o___ql.c:?",__, .4 L'" ' C--f tJ t ' .'./, I' _4 :_'\ -~ I -- h{iiicmAT~hF -p~~~Vl-- -- __-iJ1~~ """"1 II' 11;111"111 I" llllill.'l.. II.' '''(;1111''111 Pdl 11-'111 flt!.\ /Iii 11'>1 Y(>.lJII or 11''''1 01 In it 1lI1J1'--H". r'Olllpl"t" Ih" ,,'II'IWIII'l 11'1 11l1.1hl... l'q ,'111111"111 11,....111/"'1 .~-- ~-- .-----.--.--- --.- {siaNATURi-OF L!Q~~ QU~ROi^H OR CI,OBI1:Q1' ~V~I~~BI,F. Ilf.L~TI'II1:} (Q/llN^'J'URI OF W/THlnn) All .11\', I In /" II ~i'''lJuffr''.IJUll1'lll NOW, THEREFORB, In consideration 01 these considerations, and Ihe mu'ual promlslils and undertakings herelnaller set forth, and fOl' other good and yolualJla consideration, recalpt and sulllclency of which lIS hereby acl<nowledged by 8ach of the parties hel'l9to, .iUSBAND and WIFE, each Inlendlng to be legally bound, hereby covenant and agree es follows: 1. AdYlce 01 Counsel: The part lOll hereto acl<nowledge thai each hall beor, notified of hill or her rlghlto cOl1sull with coul1tlel of his or her cholca, And have buen proYlded a copy 0' Ihls agreement wllh which to consult Wltll counsel. WIFE 15 repreBented by Cerol J, Undsay. El5qulre, and HUSBAND 15 represented by Marcus A, McKnlghl, III, Euqulra. Each party acl<nowlodges and accepts thatthlll agreemenlls, In the circumstances, fair and equllable, and thai It 15 being enlered Into freely and yoluntarlly, after haYing recelyad Iluch adYlce Bnd with such knowledge all each has sought from counsel, and that e~ocutlon of this agreement 15 not Ihe result of any duress or undue Influence, and that II 15 not the resull of any Improper or Illegal agreement or agreements, 2, Automobiles: On or before October 31, 1996, HUSBAND will repair, 01 his e~pen6e, the 1992 flye.passenger Dodge MiniVan, described In the Certl/lcale of Title allBched hereto aD Exhlbll "A", and will deliver sold yehlcle to a garage of WIFE's choosing for Inspection. If WIFE's mechanic delermlnes thai the yehlcle Is In good working order and safe for WIFE 10 drive, I d;\UlJuff"I\'.IUIII~1l1 HUSBAND will transfer Ihe vehicle 10 WIFft, ThB cost of Ihe Inspocllon of the vohlcls cralled lor In this paragraph shall be paid for by WIFE, 3, Relll Estate: On or before October 31, 1996, WIFE wllle~ecute a dlled traneferrlng to HUSBAND all her right, title Bnd Inltlrest In B certain property al9 Railroad Lane, 6hlppensburg, CumlJerland County, Pennsylvania, contemporaneous with tho e)(ecullon 0' the deed, HUSBAND will pay to WIFE $1(),000,00 and WIFI: wllll11l3rl( seltled and dlsconllnued with prejudice a cel1uln landlord/tenant action Wad by WIFE In the office 01 Dlslrlct Justice Donald W, Dalhl. 4, Within ten days of Ihe dote of this Agreement, WIFF. will remove 11'0111 Ihe marital home her personalltom5 to Include 110r c1olhlng, Jewehy, tolletrl06 and mal'\oup, and 51l1allllems of senlh11enlal valul.l 10 WIFE, WIFE will provide to HUSBAND through h\G c:oun5el a list of personalty which she wishes 10 remove from the marltalhol11e, In 11113 event that WIFE requires Ii1 walk through the morltalhome In order to prepare Guchallst, HUSBAND will cooperate to pllrl11lt her to view the Items In the marital hOI11e, Within ten days after the approval of 1I10se Items W111c11 WIFE wishes to remove from the marllel home, which approval will not be unreasonably withheld by HUSBAND, WIFE will transport the Items at her own e)(pense, Prior to removal of the Ilems, HUSBAND will have the contents 01 the marital home appraised by Cllarlle Sparr of Spahr's Aucllon lor Ihe purposes 01 valuation In equitable dlstrlbullon, In the event that WIFE wishes to have another appraiser provide values for the property as well, she may do 50, Pending equitable ,\ ~, "lIl1~lfcl\",c'mcnl dlstrlbullon, both portles ogree Iho' neither will sell, give owoy, dlsslpote or allenote ony Item 01 personol property whloh wos tho property 01 the parties as 01 July 18, 1000, fI, MARITAL DEBTI HUSBAND will pay allll10rllal debt, HUSBAND reserveslhe rlghllo seel< credit lor poymenl 01 merltol debt as 0 port 01 equlloble dlslrlbullon, 6, ALIMONY PENDENrE LIrE: HUSBAND ogreoslo pay wllhout appealing Ihe Court Ordered amount 01 alimony pO/ldBl1tO /lte ollsel by eny child support obligation which WIFE may OWl!!, 7, This Agreement Is Intendod ell an Interim Agreemenl only ond not e "JII end finel sottlemenl ollhe economic Issues between the parties, While the pertles Intend Ihet the propel1y translerred herein shell be 111e sole and seperate property 01 the person to whom 1115 translerred, they also ogree that Ihe velue of thet property 1I11ell be taken Into eccounlln equlleble dlslrlbullon, No dlstrlbullve scheme Is to be Inferred Irom lhe terms ollhls Agreement, a, ModllloallCln: No modlflcollon, rescission, or amendment ollhls agreement shall be effecllve unless In wrlllng I3lgned by each 01 the parties herelo, 9, Appllcoble Low: All acls contemplaled by Ihls agreement shall be conlllrued and enforced under the laws ollhe Commonweolth 01 Pennsylvania, ~ fl)l'IUlI'IIII)' 1'11"'''1111 I,h" \1111111\.11'1' nlld hI'" 111111"1', ','h.. .",/'III1<1nlll ,:1 1 111 IIIl ,I 01110 n 1'1"lwl' l.t'II<d1 wh",'" I,h.. I'lnlIlUI'I' Willi \l1I1l11lt.( h,'1' h,t\"IIt.(IIIIoIII, 1'1I11hlllln mlt'I'llwnVll 1111,11 I.h" I'lnllllll'/"" "hllHI """Hlllt( h",' pnll', nll.1 l,hl'''W 1l,'u/llI" 1'1'011I /III ,,1""11'1,' ('I')'IIIr.l 1'''" .1111.0 I.hl.l LII/III1I.1I'I"1I II..I"lllllllllll dllHI."II)'11I1l 1I111111ll'II1HI 11.1111I11. Wh,tll lhn 1111111111 fl' /lillII'd I,h" d""","d/l"l. wh)' hI' did I. hll I. , /ltld I,hn d",'"ld,,"1. IHIII..d 11,,<'11 11111 1'1111, ,,".1 t hl""lt.,,","l 11"1' HIl)'llIill II,. would IIhllW h.'" why, Wh"1I 1.11l' \lIIlI/lt.II'I' 1'111. hilI' h'llIdl< "I' t II PI'III.",,1. h"I'II,'II', 1.11" dllr"/ld"nl. 1"'r"""1I1Iy hll. I,h.. I'loIIILlf'r'lI I.hlllllll ",,"'11,,1111011.0 1'"lll/UIO II" III'",,1111I1l 1.11" 1111111 III "I, \'"1111, I.wo "IIlCIIII, /lnd "'1\'" III!! I,h,' 1.111111111 I,ll HWI' II "lid 1111 111'11111,,01, 'I'h.. pi/lint! 1'1' HIIII"hl, 1,1,..,,111I1'111. Ill. t.h.l e"I'1I",J" lIolll'ltlll "or. I.h" III,jlll'I.." 11/101 1'11<,01 """I'll"" "1l,,11I"1. 1.11.. dllf'..nd/lnl. with th" 1"'1ln,,)'lv,"i11l SI.IlI... 1'011".., b, 1/1 Ill' ,,110111. All!!'I"1. Hlllll, thl' dnl"'l1dl\nl, <1<11'1101'..01 t.h~ 1'1"IIILlI'/, III " 1l'\I'''!!'' 1'01' 1l111"'Oxlllli\t"l)' 0111' hollr with "J I 1.111' 01001'" "ll.h"I' 111c!\l'd 01' blocl\l1d "0 t.hllt Hhll eOllld /IIII'. "Helll'" CllllHI/l1l h"I' tel ""/\1' I'OJ' h"l' Hn/'fl'ty, Olll'lnll I.h,' 1/1,,101,,"1., thl! d..f'''/Ir.lllnt j'nr""/'lItJ)' Ilrllbbcd t.h~ 111,11111'.11'1' by h"I' 111'111 <:'''IHlnll hl'lIlHl'A, pinned her 1l1l1l11lHt. /1 w,lll holdlllll he,' wdllt l'llllaln!!! brlllH'Hil, t.hl'IHlt"J1erl 1.0 hit. till! pllllnt.lt'f In t.1ll! I'IICo, r1rnw b,lCllt hili /'I"t., Illld hit. th.' WillI dll'c"Uy b.udrlc th" 2 pll\llItlff'K hUl\d, c, In 1\"1"'0",11111\1.01)/ HlIH, \,ho ,lo"lln.I'lllt. lI/'llllborl ';h., pl"llnt.1 "I' h)' hilI' thl'~lIl1. I\nrl KIIIIIIIII~lrI ho.' 1I111111111t. 1\ will' ~"11I1I11I1Il lillI' 1m III, 1\, 'I'ho pllllnl.ll'" h." 1~'VUll MlrI th.,,'ul")J'" /iVrJI'1i thllt lihe III In IlIIlI1orlllll.u Ilnil P,'IIHulIl. ilIIIIIl".' I)" 1\111.1111 1'1'<1111 tho r1nj'nnrllH't. lUll I tlilll. IIhn III 111 110,'rI 01' PI"lt<H!l.loll 1'1"1111 HII'!!I IIlllllHh /1, 'l'Iio "I III nl.l 1'" rlllHll'OH thllt I.hu,lul'ollrllllll. 110 prohlblLlld 1'1'0111 hllvllIll 1111)/ "I,'nd, III' 11I"!"<H!1. C<lllt,wt, wll.h t.ha pl,lInl.ll'f IlIoJllrltrll', hilt. 1101. 111II11.1lI1 1.11, tnlul1holllJ IIlIrI Wl'ltt,," (!OllllllllnI CHlI.IOIlH, """1I.lpt I'ol'tho 1IIIIII.1II111111'POHO 01' fllclllt.lIl.lnll IJII/ltorl)/ 'II'.' II II I! II IIIfl II 1.11 , 7, '1'1111 pllllllt.t 1'1' "llllll'~'H I.hllt. tt,~. .1<"'1111""111. lIu oIlJol/lD.1 1'1'0111 hllrlllllllllll Ilnrl Kt.,lllllnll t.ho pllllnlll'l', Illld 1'1'0111 hllL'/lKllIi/1I1 t.h., plllllll.ll'l"/I rullltlvoH, 8, Tho pJ/lIIlt.t 1'1' ,lc'HlruH I.hlll. tho ""fl'lIdlllll. b~l 1'''lltr,llned 1'1'0111 DlIl.orlnll hor pt/lCD of olllplo)/lIIonl., ~, Tho plllllll.lrf dOHlroH I.h/ll. tho "ornlldlllll. bo ellJolned 1'1'0111 rOll1ovlnll, "1\1111111 Inll , r111Ilt.ro)/lnll or IIllllllIll /111)/ proport)' owned JoIIII.I)' b)/ I.ho pBrtloH or oWllod Holely b)/ tho plllllltll'l', UL__ J~Xm!IIl'lJ VI'; .POIlIlJl,l.Iff ION 10, Tho hOllln wh!uh th" plllllltlrr III IIHkinll tho COllrt to order thu del'en""lll. to al.llY IlWIlY 1'1'0111 III nol. owned or ronLed in t.he dol'olldllnt'H IIl1l11e. II. Tho rlnfendnnt hllll hili IIWII rnllldellco l<lcnt.ed at 2' Broad :1 tH rlt" I, , tihlppollHhllrH, 1'01lIlHyl\llIlIllI. U ,,_,-I,01l1JI.;II. AND _1lI::JHllUIlIfHHmi'r . FOIl._COll'l.'. DJ.1.p'JAIJJt; 1:1, 'I'hl) 1'11111111 "I' hllll HII"'''I'.,,1 1"IlHllH IIIl /1 "1I1l1l1l. '1' t.h" IIhlllll' by I.h.. ,1"""1101'1111., 'l'he IIIH/HIH /11'11 11111.1:1.1011 I,,,hlhlt A 1II.l,II,d,,,,\ , 1:1, 'l'hl:l 1'111111111'1' 1I1l1111 I,hlll. till> 01"""110111'11. b" 1I,'d''''"d to ll/IY ':lnll,OO to 1'''llIIlIlI''H'' UII" U" l."lllll 8''''\lI<:''H, JIIf', IH I'IIII.111I1l "'HII'CIIH "lll' th.' "',IHI. lit' IlI.l!!III,\1I1( IlilH ':/lHll, WII h;llI': 1"011/0: , IJlII'HII/lIII. 1.0 I.h" 1'1"'\11 HI<IIlH ot' I,hll "1"'I/I,ltcl.lun "1'0111 MIlIH" AnI" of' (kl,olll'l' 7, 11171\, :13 PII,C:,8, " III II I 1fI.t Iill.!!" 1111 1Il11l1l1dod, t.lIl' pl'IIIII.\I'r 1>l',IYH I.hlH "')1101'11111" C'"IJ'1. l.n !!I'III1I: I.hll rollowlllll 1',,11,'1'1 A, 11"11111, II '1'''IIII")rIlI"Y O,'d,,,' I'U rH1I/l1I I, 1.0 1.11" "PI'ol.,'.'l.Io11 1"'0111 MIlIHII Actl" I. OI',t,,1'I1I1( I.h.. oI""IIt1dlllll. 1.0 1',,"I'1i11l ""1)111 IIllll/tlnl( Iho plllllll,II'I' Ill' pllldllK hilI' III r,,"r 01' IIbIlHI', 2, Ol'd",'11I1{ Ih" oI,,""lIdlllll, 1..) ",'1"'11111 fro," hllY1IIll IItly .III'"d, 01' 1110111-",,1. cllnl.llr:t with I.ho plllllll.lrr I 1I,'llIdllll(, hll I tlot I 111111.,.01 1.0, 1."\OPhollll 1111.1 lirll,I,II11 ':OIllIllIlI1I"III,loIIH, """"pt 1.1/ 1'/I[!IIII,lIto "IIHI.orly 111"'/1111("/1"'11 I. H , :), Ol'oI'.','III!! I.h.' 01"""110111111, 1,0 I''''!'lIln 1'1'0111 hlll'IIHHIiI!l 111101 HI.IIIIIIIII{ th.. I'lllllll.lff IIn" rrotn hllrllHHll11{ I.h.. 1'1/111111 fr'H I'"IIIIIYI'H, ,I -I. \1I'llhlllll,I"14 I,hn IIII"nndlllll. r/'lllll Itnl.ul'ln" th... II\Illnl,II'I"K 1I1111m Ill' Itlllplu)'lII$nl', II. PI'ohllllLlnl( t,hl' d,,"',tllllnlll. "'011I I'fllllovln". 111111I111(111141 .IItKI,l'oyIIlN III' HilI Ilnll PI'OPI!I'I.)' ,jl) I Ilt.l 'I ClW II 1111 \ly I.li.. pIII'IIU" '11' OWlltl'! I.wl")y II)' I.ho II' 111111.11'(, 1\. Ot'dul'i Ill( I,lilt d..r"lldnllt, 1.0 HI.II'I IIWIIY "1"011I tlil! 1I11111ltl r,"H "llKI.I""I,',' )'""II."rI nl. 141\ Ill/Ktlo I1l'1vo. l.ul. 1\:\, Hlilpl'/lllltlllll'MI ClIlllbot'lllIld C<lIlIll,'1, P"lltllAyl VIlIIIII , whl.!h Iho 1"lrl,luK hllv" ''''VOI' Hhlll""" I IInrl 1111'1 ol,liltl' l'rlHldnllcl' I.ho pI 111111.1 1'1' mn)' <Htl.llbIIHh, 13, S.:lIlt1lul.' 1\ hun,'11I1.I III nl!I'III'IJnn',p' wll.h I.h,' 111'1) V III 101111 0" tho "1'rut<,<:l.Iol1 I'rum AhllKlt AI:I.," /l11r1, 111'1.0" KliCh h<lIlrlnll. otll.or /111 0,'1101' to h.. III "rl'IId, "01' n 1"','lorl of' onll '1<'/11'1 I, O/',ln,'11I1( I. hI' dnrnllrllllll. 1.0 refrlllll ""om IIbllKlnl.l I.h<' pI 111111.1 1'1' <)I' Vlndhl.l h'>I' In I'llllr 01' IIll1lllu, 2. Cl,'rlltl'lnl.l I. h.' ,1<,,',,111111111 I.u r(.r"llltl 1'1"0111 h/lvltll& 1111)' III I'llI' I. or ItI,II""d. .,ullt,,,d, wlt.h I.hu pl,1Inl.lfr III" 1 Ilrl 1111.1 , bill. 1101. II mll.ltrl to, 1,<'1 "phonr~ 1111" w,'ll.l.ulIl'olllllllllllr:nl.lollH, IIX<,UPI. 1.0 fll"lllt./ll.u clllll.ud)' 1lI"'IlIlI&"II1I'IlI./l, :\, Orllll"llIl( 1.111' dl,,'llllrllllll. 1.0 1'01"'11111 frullI hllt'Ill<HII1/( "lid HI."IIIIIII.I t.h" pl/llllllrf /III" r,'ullI ~ hlll"II>IIII"., Ihlt 111111111.11'1"11 "lIllIl.lv','H. 4, P,'ohlbll,III" 1,1111 oI".',,"r1l1nl, f/'lllll ,,"l.ul'Il111 \.II" 111,11111.1 ","H pili'''' 0" "11I111 o Y III" 11 1 , 1\, l'/'ulllhll,11I14 1110 01111""11111111. ""')11I "" IIILl V 111M , .!I'IIII1I4II11(, rI"III,"'llyIIIM ,)I' 1I111111l" P"OI,,,,'I,y ,jollll.ly nWlIlld hy 1.1111 1I/II't.l",. 0" llWlIllol IInl..ly by I.hll II 1111111.11' I' . 1\, Ol'rllIl'llIl4 I.h.. <101''''11111111. 1.11 lil.llY IIWIlY ""011I th.l pllIllIl.lff"H 1'lIHlrI''IwIl Im'III,,,rI III. 1411 HIIHl.lc Ill'lve, I,nl, II:!, HII IPP""l1hlll'!!l, Clllllh., 1'I,"ld ClllIlIl.y, P''IIIIIIY 1\11111111, wh 1.,11 I,ll" 1'"1'1.1'111 h"\lo I1ll\lur IIhllrllrl, 1I11r1 III1Y .)I.h,'" ""lilol"II'''' thu 1I1111111.11'" III11Y ,,"l.lIbll 1111, 7. O,'rI",'11I14 1.11.. oI'''''>I1'\lInl. 1.0 .,..llIIbll.'HU I.hu plllllll.ll'l"lI ')\II.-n,',-".",llul. "HHiIlH lilll'l"ll"!I1 IlII /. 1"'''111 I. ll" I.h" 111:11111" I /lC IlIrI 1 III( bit t. /lOt. I j IIIlted 1.0 thll !.llllll'Hi II HI."d Oil l,h" III.I.,..:hau HII"ol. lII11rkod F.x h I III t ^, 8, O.'rI"rllll( 1.111' ,1t!l',,"o1l1nl. t.o Il/1Y $2110.00 t.n "'!\IIII11Il'II" 01111 01' 1."14111 S""\I I<:llll , Tnc,'1I I'lllJdlnl4 lI<llll'<:'.1I 1'01' t.ho <:0111. IJI' 1I111(1It.lrl!l I,hl", C'UI<' , 'l'hu 1>1111111,11'1' 1'111'1.11"" 11",11'" I.h,lt. I.hl", P"t.lUll/l bll I'llod IIl1d 1101'\1001 wlt.holll. 1'11)/11I"111. of .""'11 11I101 COllt.", by t.lw pllllllt,ll'f, I'onollllll II fllrl.lI.,,' ')I'd,"' III. I.ho hl.'lIrl/ll(, IInol I.II11t, .!nrt.l.florJ cop 1011 or I.hlH Plll.Jtlon /HId O,'dor bl! dllll \/("'!HI to t.he """I1"'y1\1111111 Sl.llte 1\ 0 ~ i" ":1 >, "1 / ..... 110) II!, .. , .. '~ ".t ,,' I' , , I:~) , ~ , I, "I ~ . " ~ L, ,,' , , , , !' , . 'II ,I v. I IN 'I'm: COlllt'l' Oil COMMON I'UAS OIl I CUMln:IU.ANJ> COllNTY, l't:NNSYI,VANIA I I CIVIL ACTION - LAW r I 911-C:'tll CIVIL n:ItM I I IlltOn:C'1'I0N 1,'IWI\t Alll/BE JIWIIEIW L, S'I'OUlllll!:R, I'fll'hllllr LOJum: A. STOUlllllm, Itf1llOnd,.., l:EMI'OItAltY 1"U>TI':CJ'lV": OItJ)lm ANI) NOW, IhlK ,,~c;tdIlY of Deccmbcr, 1')1)6, UpOIl prCKC/ltllllollllnd cOIl~ldernllon of the wllhln PClllloll, IInd upon Iilldlllg IlulI Jcll'eIY L Sloull'er, 1l0W rCKldlnlll1l Cllmberlnnd COUIllY, PCl1Iuylvnlllu, Is In Illlllledlllle IIIllI prescllI dllllllcr of IIbuKe Ihull lhe reKpolldent. Lorrie A, Stouflcr, the filllowllll! Tempornry Order Is cntered: The rcspondcnl, L.I)ITlc A Sloufl'er, whos,: curre/lt IIddresK 16 146 RIISllc Drive, Lot 53, Shlppeluburll, PenllsylvlIlIllI 17257, Is hcrcby enjolncd Ihull physlclllly IIbllS11l1l the pelltloller, Jell'cry L. Stoull'er, IlI1dlhch chlldrcll, Justlll M, Sloull'er, Brnlldoll L. S\llull'cr, Corey A, Slouflcr und ShllW1l11I M, Sloufl'cr, or plllcllllllhemlll f'ellr or IIbuse ulld Is ordcred III KIUy IIWIlY Iromllny loelltlon whcre they mllY rcslde, The respolldc/lt Is hcrcby Ilotlfied thllt If she 1IIIIs to rollow Ihl6 Order, she mllY bc III Indlrccl crlmlnlll COlllempl which Is punlshllble by II IInc Ilot to exceed $1,000,00 IIlld/or by II selltellce of lip to six mOlllhsln jl\lllIlld uny other IIpproprhile pUllishmellt. ResulllpllOIl or co-resldellce 011 the pllrl of the petltll)ncr lllld the respollde/lt shull not Ilulllfy the provisions of the court order dlrectllllllhe reSplllldel1l to relrulll Irom llbuslnll the pelllloller nnd their children, \ THI~ r.:J,&t ."nr.A.O r....,,.,.... ,'" .(&l.~ "..~..Q r. ",".~ uulN ~ .o.;..WtJ .;.. JI~ (""4", A k.I..., ''''\. ~\.".Jj. lw. NA...t ..... ~ '1....-10.,. 1M k 5"'" Y~F" l:uu~lu.t, /''i1e" ..;f /1114' fI"", .;. c..., I"~' ll., (,--.I1"'(.....J. (_~, (_I~, \o-"U, Ii...~........., The Cumberlund County Sh~rlll'l Ol1lclI shllll nllllmpl 10 mllkll 6111'VIcIl ul Ihe Ilclllloncl'l requell, bUI IlIrvlcll nlllY bellccomfJII5hlld IInd~r IIny nppllcnbllll1J1llor Clvlll'roc~dure, The rlllpondllnt II hcrllby IIxclud~d Ii'om Ihll rllsldlllll'lI or Ihll pllllllollllr, locllllld III 21 Broad Slreet, Shlppclllburll, Pelll15ylvanlll I72S7, She Is hllrllby ordllrlld 10 51uy aWIlY from snld rClldencc, The Pllnn5ylvonln SIUle POIICII, Cnrll5111 Sub5lnllon, Wnrden of Ihe Cumbel'land C:OUllly Prllon, Sherill' or CUll1berlnnd County, thll Dlmict JU511clI, nnd Ihll Mid Cumbllrlund Relllonul Ilollce Dellortmel1l will be provided with 0 copy or Ihls Order by ollollleys lor pelllloner, Thll Ordcr sholl he enforced by IIny low enforcemenl "1lllncy where 0 vlollltlon occurs by nrrclI lor Indlrecl crhnlnRI contempt wlthoul Wllrrllnl upon proboblll clluselhlltthls Order hUI been vlololed, whllthcr or Ilotthe vlollltlon II cOlllmltted Inlhe pre5enCll or thll pollclI olllc~r, In the cvelltthol an lUTelt II mod~ under thll IIlClloll, the rll5pOndel1l 5holl bll tukell without UIlIll:CCI6Ary dclay beforclhe court Ihot luued thll Order. Whell that court II ullllvnlluble, thc rClpondcll' shall be arralgncd before Ihe appropriate district JU511ee, (23 PII,C,S,A, ~t\ 113), j/ J. / ,I i' 2 . . . , , Jane Muller.Petenson, Esquire ' IV For Petitioner/Respondent J,O~,,;... ')~114" Marous A. MoKnlght, III, Esquire IJ. ~ For Re.pondenl/PetltJoner :881